In aortic dissection a tear in the inner layer of the aorta lets blood split the wall apart, creating a false channel that can block branches or rupture. High blood pressure is the main risk factor, and type A dissections involving the ascending aorta need emergency surgery.
Key symptoms
- Sudden, severe chest or back pain, often described as tearing or ripping
- Pain that moves as the tear spreads
- Fainting
- Stroke-like symptoms or a cold, painful limb
- Abdominal pain if gut arteries are involved
What you find on exam
- Blood pressure difference of more than 20 mmHg between the arms
- Weak or missing pulses
- New diastolic murmur of aortic regurgitation
- Neurologic deficits
- Signs of tamponade or shock
Tests
- CT angiography of the chest, abdomen and pelvis
- Transesophageal echocardiogram if too unstable for CT
- ECG and troponin to look for coronary involvement
- Chest X-ray may show a wide mediastinum
- Type and crossmatch, kidney function, lactate
Treatment basics
- IV esmolol or labetalol first: heart rate below 60 and systolic pressure 100 to 120 mmHg
- Pain control with IV opioids
- Type A: emergency cardiac surgery
- Type B: usually medical, with endovascular repair if complications
- Avoid anticoagulants and thrombolytics
Red flags
- Low blood pressure or signs of tamponade
- New neurologic deficit or cold limb
- Severe pain that persists despite treatment
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Sources: NASEMSO National Model EMS Clinical Guidelines; NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations. Written by Making Synapses. Making Synapses is not affiliated with these organizations.